4 UNION ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One-or Two-Fondly Dwelling Ext 118
-�� This S ton or Official Use Only
Buildtng.Bermit Number: Date Applied: • U
Signature: I • L4 %, OCl
Building Commissioner/Inspecto f Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel:Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: -'
i
Zoning District Proposed Use Lot Area(sq B) Frontage(It)
1.5.Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of Record:
Name(Print) Address for Service:
CI`tR 7tiU fc tic;
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑1 Existing Buildin -Owner-Occupiedcla, Repairs(sk_4Zl_ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1Number oFLinits Other ❑ Specify:_-_._
Brief Description of Proposed Work': hi j� inJ, n r� w Rn n V7 '"'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ 7� /
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: $
6. Total Project Cost: $
_ U Check No. Check Amount: Cash Amount:
' (� ��
J 0Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 tLicensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder __ List CSL Type(see below)
U Cy.P"A ) &7 �,1>,O '4' o 'v Type Description
Address U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Si nature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
• SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registere Home Improvement Contractor(HIC)
l o 'r b L✓ Cc� (_ cs
WIC Name or HI Re t ranIN ame Registration Number
C Company 1� c��� a ir-c K 2
Ad e s ry
E )iratian Date
Sionamrr . Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑ .
SECTION 7a: OWNER AU,HORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I
1 , as Owner of the subject property hereby I
authorize to act on my behalf, in all matters
relative to work authorized by this!wilding permit application.
Signature of Owner ----_----_-----__�-- -- Date .�
j SECT ION 7b: _OW_NEW OR AUTHORIZED AGENT DECLARATION �
1 {,._�'>../ �, b.v Li(C��. T_ ___ ,as Owner o Authorized Agen ereby declaie l
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
,7' R t ws
Print Name _ 9
_
Signature of Owner o uthorize ent Date
A
(Signed under the pains and penalties of edu
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.)- Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 01111
www'mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeeibIv
Name (]3wmess/Orgmizabon/Individml):
Address: / 4 M t 2/ S`r
G O qCity/State/Zip:
Are you an employer?Check the appropriate box: Type of project(required):
1.1ST I am a employer 1
to er with 4. ❑ I am a general contractor and I
- --�� 6. El New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sale proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub ccntractors have g. ❑ Demolition -
working for me in any capacity. employees and have workers' 9. addition
[No workers' comp.insurance comp.insmance.t ❑ Building
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LFJ Phunbing repairs or additions
myself. [No workers' camp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 new also fill out the section below showing their workers'compensation policy information.
t Honeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
-=Contractors that check this box most attached an additional street showing the name of the subcontractor and state whether or not those entities have
enWloyees. If the sub-contractors have artployces,they must ptrnide their workers'comp.policy number.'
I am an employer that Is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: lr
Policy#or Self-ins.Lic.#: Et 0 [ C Ci 7 G I a C O:'R Expiration Date C: C - O"3- 9
Job Site Address:^4 ( J N r-e .s '6 t City/State/Zip:S A l n nn i�l A Q \ ci'\0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties m the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: . mott^^—J < a Date:.
Phone#: Ct J 3� .
Offrcial use only. Do not write In this area,to be completed by city or town ofjlcial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
3 9 ; ISSUE DATE 0713112008
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Edward F Sennott Insurance CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS CERTIFICATE
Agency Inc DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
16 South Main Street
opsfield,MA 01983 COMPANIES AFFORDING COVERAGE
INSURED
Len Gibely CGntraoting Company Inc
8 Jenness Street COMPANY A A.I.M. Mutual Insurance Co
Beverly,MA 01915 LETTER
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF I NSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE(MM/DD(YY) DATE(MMIDD/YY)
GENERAL LIABILITY GENERAL AGGREGATE
PRODUCTS-COMPIOP AGO.
=COMMERCIAL GENERAL LIABILITY PERSONAL 4 ADV.INJURY
=CLAIMS MADE=OCCUR
EACH OCCURRENCE
OWNER'S k CONTRACTOR'S PROT.
FIRE DAMAGE(Anyone tin)
FED.EXPENSE(Anyone person)
AUTOMOBILE LIABILITY
COMBINED SINGLE 1
LIMB
ANY AUTO BODILY INJURY
ALL OWNED AUTOS (per pence
SCHEDULED AUTOS
HIRED AUTOS
NON-0"ED AUTOS BODILY INJURY
GARAGE LIABILITY (Per acciEcnq
PROPERTY DAMAGE
EXCESS LIABILITY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM [ '
WORKERS COMPENSATION AND STATUTORY LIMITS OTHER
EMPLOYERS LIABILITY X
E PROPRIETOR/ EL EACH ACCIDENT $ 500,000
A ARNERSIEXECUTTPE
FFICIERSARE 6010979012008 08/03/2008 08/03/2009 EL DISEASE--POLICY LIMIT S 500,000
MCL EXCL
EL DISEASE--EACH 500,000
EMPLOYEE
COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
NGELA SIRONI THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL JO WRITTEN NOTICE TO THE CERTIFICATE
OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION
/O GIBELY R LIABILITY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES.
149 MAIN ST
PEABODY,MA 01960 AUTHORIZED REPRESENTATIVE
� I
Page Na i of 'I pages
• LEN GIBELY CONTRACTING CO., INC. y
149,Main Street 19270PROPOSAL rT
PEASOD,Y, MASSACHUSETTS 01960
All home Improvement contractors and subcontractors
engaged In home Improvement contracting,unless i
(978)531.8234 specifically exempt from registration by Provisions of
- FAX(978)531.9304 Chapter 142A of the general laws,must be registered 1«'.
- Submined S 1 with the Commonwealth of Massachusetts.Inquiries J d;
To: about registration and status should be made to the 2"
Director, Home Improvement Contract Registration, ,F5
One Ashburton Place, Room 1301,Boston,MA 02108
(617) 727.8598. Owners who secure their own
construction related permits or deal with unregistered
contractors will be excluded from the Guaranty Fund
Provision of Not.c.142A. s
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ew (debt.Owning Beer caused by Clmumne xes BepYvM�,B Conur .cont,a,eq wrk Wu tie mmpeaa b/ 1.The 0e*x herebytsaddAngBass ea apPmOnweW ouBsuob delS'etlm as nit awlWue ey Be VlnBsoxt NSW M,�M�/ YbYtlpleaWeAVesnenL
1tw caNscb WYle1e ess Bw ePY NmINM 1 ndw"W 1.f.darts h..W and xaM1manYtlp 1 apebda3 Y�bAwIM Canpleaan end sNeA wmalY YAB,
BY.nswenw,uaNMApsa,eia!Nee ewN erydsaahweenuuXip or mearleb.adanep wusedwBa Convemo.MsuewnVaobn.ew,�eeaey�asn�uM1,,b Besowad regeexed. ..�.
- on werwwnwabnaary ls0.eons awn up ew C.ontrauldr el,eO,aXle o.n eXPenN,MmwM rmmeBy.afar.bones;aeeae.wnwebb,YMW.apalM,a aB, 4
' me mrapeamn man naadab w xwemu,sap m bawha wamnllx else survM art wp.eBon redanw0 h rmnealon eW,U1s epeedtem earh.
We Prop08eereby to furnlah material and labor-complete In accordance with above specifications,for the sum of: c
L . ...:`Y...:-....c. r
Pey�oent dollars
X.meaco-6�1 n.pin,:m
.a^F.e,,yry
.. .:oarWetlanolwork untlermb moves. - ._ -. � .. . waem lc so-
Notlmafb apsenwnt tar tuna lmprovMlenl ooneastlnp wart atWl,pula edown
PCRnamunt Or sep W6 ofannos onaftcathe totalsonlrect txb:or the -
toW amountdh WBenme wlWmenay 0 speacbamibr must end in eWan t. -
b ONer.eltlM oIMRNu:abWn deWmy a epat4l other melaNb arM seulpment,
. r ,[ .. . - Xou:TX.waeaa�uwmme,mgwnr,w mpeawmwTdaa ..
Acceptance vt Proposal I have read both sides of this document and accept the prime,specifications and conditions stated.I understand
Net Uponggning;tltiB PIpD?aal 60WM e a binding contract. You ere authorized to do the work as specified. Payment will be made as oWined above.
You,the Buyer;may cancel this transaction at any time prior to midnight of the third business day after -
the date of this transaction.Cancellation must be done In writing.
a .. DO,NOT S!QJ4 THIS CONTRACT IF THERE ARE ANY BLANK SPACES."
sy3 yr '�i2 wit Zg �s!waa Iwr .-
a x c IMPORTANT INFORMATION ON BACK I► Y-
V .,
r {{
1-y Ada
fry
U✓�ee �orirnovr<aerrloi r�,�iruaercu,e/A
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 100811
Expiration: &2312010 Trill 268971
Type: Private Corporation
LEN GIBELY CONTRACTING CO.:.INC.
Brian Dobbins
149 Main Street
Peabody, MA 01960 Administrator
O
BOARD OF BUILDING REGULATIONS -
'`"1 ". License: CONSTRUCTION SUPERVISOR
`i Number CS 094763
Birthdate:'05/1411943
Expires; 051141201Q Tr.no: $4753
Restricted: 00
�> 7 THOMAS R DOBBINS
19 CEDAR HILL DRIVE G--
DANVERS, MA 01923
Comm 'I